NEW IBD impairment listing effective December 18, 2007!
Applying for Benefits
Many IBD patients have learned an unfortunate paradox of dealing with a chronic disease-it often seems that the sicker we get, the more adversarial the social systems designed to protect us become. If your disease has become severe enough for you to consider filing for disability, the process of qualifying can be overwhelming-often filled with complex regulations, ambiguous interpretations, frequent disappointments, and endless delays. Below are some questions and answers that may help you understand how the application and appeal processes work should you need to apply for disability benefits.
What is Disability Insurance?
Basically, disability insurance provides income to people with medical conditions that are so severe they are unable to work. Employers may offer group long term disability (LTD) plans, and individual plans can be purchased from many insurance companies. However, as with health insurance, individual plans are medically underwritten, and for people with IBD, very costly, if available at all. The type of insurance you have will determine the claims and appeal process you must follow to receive benefits. Since LTD and individual plans vary, check your plan document for information on filing a claim and/or an appeal.
What Types of Disability Benefits Are Available through the Social Security Administration?
In addition to premium-based programs like LTD and individual disability plans, a 1956 amendment to the Social Security Act of 1935 provided for two types of monthly benefits payments to be paid to individuals who cannot work due to a disability. Social Security Disability Insurance (SSDI), created by Title II of the Act, provides income for disabled people under age 65, who have worked in recent years (generally, 5 out of the last 10 years) and paid Social Security taxes. SSDI is not based on need, but on the recipient's past contributions (or those of a parent or spouse) to the Social Security trust fund.
Supplemental Security Income (SSI), created under Title XVI, covers disabled people who have never been able to work, or who worked so little or so long ago that they are not eligible for SSDI. SSI eligibility is determined on the basis of financial need. The medical requirements and determination process are the same for both programs.
Both programs define a disability as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to last for a continuous period of not less than 12 months or result in death." In simple language, your illness makes you incapable of working enough to earn anything significant. The Social Security Administration (SSA) defines a medically determinable impairment as "an impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques."
Who is Eligible for SSDI?
Basically, you are eligible if:
- You have contributed to a Social Security account while working for a specified period of time, usually 5 out of the last ten years of work;
- You meet the SSA's definition of disabled;
- You are currently not working, or you are working, but earning less than the amount considered to be the substantial gainful activity level ($800 in 2003).
Family members of SSDI recipients may also be eligible for benefits. Eligible family members include:
- Any unmarried children under 18 or age 19 if they are in high school full time. (This includes adopted children, and, in some cases, stepchildren or grandchildren);
- Unmarried children, 18 or older, may qualify if they have a disability that started before the age of 22 and if they meet the adult definition of disability;
- A spouse who is age 62 or older, or any age if he or she is caring for a child of the recipient who is under age 16, or disabled and also receiving checks;
- A disabled widow or widower age 50 or older. The disability must have started before, or within seven years after, the spouse's death. (Widows or widowers who receive Social Security benefits because they are caring for a recipient's children are eligible if they become disabled before, or within seven years after, those payments end.)
Who Is Eligible for SSI?
In order to receive SSI, or Supplemental Security Income, you must be age 65 or older, disabled or blind, and not exceed eligibility limits for income and assets. SSI also pays disability benefits to disabled or blind children who are under 18 years old, whose families have limited income and resources. People who get SSI can usually qualify for other assistance programs, such as food stamps and Medicaid.
Am I Considered Disabled?
Once you have determined that you fall into an eligible category, to receive benefits you must demonstrate that you are "disabled" by the Act's standards. Basically, 'disabled' means that you suffer from a physical or mental health problem (or a combination of problems) that makes you unable to do any kind of work. In addition, your disability is expected to last for at least a year or to result in death. The Social Security Administration uses five sequential questions to determine whether someone qualifies as disabled:
- Are you working? If you have earnings averaging more than $780 a month in 2002 or $800 a month in 2003, you generally are not considered disabled.
- Is your condition severe? Do you have a diagnosed condition that is severe enough to prevent you from performing basic work-related tasks?
- Is your condition found in the list of disabling impairments? The Social Security Administration's Handbook for Physicians contains a "Listing of Impairments" for each of the major body systems. It catalogs impairments that are considered severe enough to prevent a person from performing any gainful activity (or in the case of children under age 18 applying for SSI, cause marked and severe functional limitations). Most of these impairments are permanent or are expected to result in death, or have a specific duration. For the others, the impairment must have lasted or be expected to last for a continuous period of at least 12 months. The criteria in the Listing of Impairments are applicable to evaluation of claims under both the Social Security disability insurance and SSI programs. If your condition is on the list, you are automatically approved for benefits. If it is not on the list, the SSA determines whether your condition "meets the listing," i.e., is as severe as an impairment on the list. If it is, your claim is approved. If not, your claim is further scrutinized under the next requirement.
- Can you do the work you did previously? If your condition is severe, but not of the same or equal severity as an impairment on the list, then the SSA determines whether your medical documentation shows that you cannot reasonably be expected to do the work you have done in the last 15 years. If it does not, your claim will be denied. If it does, your claim will be considered further.
- Can you do any other type of work? If you cannot do the work you did in the last 15 years, then it will be determined whether you can do any other type of work. Taking into consideration your age, education, past work experience, and transferable skills, the SSA will review the job demands of any other job which "exists in significant numbers" in the national economy, as determined by the Department of Labor. If you cannot do any other kind of work, your claim will be approved. If you can, your claim will be denied.
How Do I Apply?
You can apply for Security Disability Insurance (SSDI) benefits online, by phone, mail or by visiting the nearest office as soon as you become disabled.
You may apply online or by phone, toll-free at 1-800-772-1213 from 7 a.m. and 7 p.m., Monday through Friday. Representatives will give you an appointment for your application to be taken over the telephone. For people who are deaf or hard of hearing, the SSA provides a toll-free "TTY" number: 1-800-325-0778. You can also apply at any Social Security office. You can find the name and address of the closest Social Security office.
The SSA estimates that the initial claims process for disability benefits generally takes from 90 to 120 days. However, being prepared with the necessary documents and medical evidence can help shorten the process.
What Information Will I Need to Provide?
The SSA requires original documents (or copies certified by the issuing agency) of:
- Your birth certificate or other proof of birth;
- Your Citizenship or Naturalization papers (if applicable).
The SSA will accept copies of:
- Your U.S. Military Service discharge paper(s) if you have served in the military;
- Your W-2 Form (Wage and Tax Statement), or if you are self-employed, your federal tax return for the past year.
In addition, you will need to supply:
Your Social Security number;
- A summary of where you worked in the past 15 years and the kind of work you did;
- The names and addresses of each employer for this year and last year;
- The amount you earned last year and the amount you expect to earn this year (between September and December, you may also be asked to estimate how much you expect to earn next year);
- Names, addresses, phone numbers and dates of treatment for doctors, hospitals, clinics, and institutions that provided treatment for the disabling condition;
- Medical records from your doctors, therapists, hospitals, clinics, and caseworkers, including the names of all medications you are taking, and all laboratory and test results;
- The beginning and ending dates for any period of U.S. military service you may have served;
- If your spouse and/or children are applying for benefits, you will need their birth certificates and Social Security numbers;
- If you have ever been married, the name, Social Security number, and date of birth of your current and/or any prior spouse, the date and place of each marriage and, if applicable, the date and place the marriage ended;
- Your bank account number and your bank or financial institution's routing transit number, so your benefits can be deposited electronically into your account.
If you are applying for Supplemental Security Income benefits you will also need to provide:
- Financial records, such as payroll slips, bank books, insurance policies, car registration, burial fund records, and other information about your income and the things you own;
- Information about your home, such as your mortgage or your lease and landlord's name.
When Will My Benefits Start?
If your SSDI claim is approved, you will receive benefits beginning with the sixth full month after the date that it is determined your disability began.
For Supplemental Security Income (SSI), benefits are paid for the first full month after the date you filed your claim, or the date you become eligible for SSI, if that is later.
How Much Will My Benefit Be?
The amount of your monthly disability benefit is based on your lifetime average earnings covered by Social Security. The Social Security Administration provides a statement that will tell you the amount of the benefit you have accrued. Request a statement.
How Long Will the Benefits Last?
Benefits usually continue until you are able to work again on a regular basis. There are also a number of special rules, called "work incentives," that provide continued benefits and health care coverage to help you make the transition back to work. Information about work incentives can be found on the Social Security web site at: www.ssa.gov
In addition, there are a number of circumstances that could cause SSA to discontinue your benefits. These are detailed on the Social Security web site at: www.ssa.gov
If you are receiving Social Security disability benefits when you reach age 65, your disability benefits automatically convert to retirement benefits, but the amount remains the same.
Do I Really Have a Chance at Winning My Claim?
Because the severity of IBD is often hard to measure empirically, it can be difficult to prove disability, but many people with IBD have been successful at winning their claims. With supportive doctors, consistent and well-documented evidence, competent legal representation-and a large dose of perseverance-it can be done.
For further information, call CCFA at our Information Resource Center: 888.MY.GUT.PAIN (888.694.8872).
The Crohn’s & Colitis Foundation of America provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.
About this resource
Published: February 1, 2008